DOES QUALITY OF COUNSELING AND EXPOSURE TO FAMILY PLANNING MESSAGES INFLUENCE THE USE OF MODERN CONTRACEPTIVES AMONG WOMEN IN NORTHERN NIGERIA?

DOES QUALITY OF COUNSELING AND EXPOSURE TO FAMILY PLANNING MESSAGES INFLUENCE THE USE OF MODERN CONTRACEPTIVES AMONG WOMEN IN NORTHERN NIGERIA? | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search DOES QUALITY OF COUNSELING AND EXPOSURE TO FAMILY PLANNING MESSAGES INFLUENCE THE USE OF MODERN CONTRACEPTIVES AMONG WOMEN IN NORTHERN NIGERIA? View ORCID Profile Matthew Alabi , Leanne Dougherty , Eno-Obong Etim , View ORCID Profile Adebola Adedimeji doi: https://doi.org/10.1101/2024.04.03.24305214 Matthew Alabi 1,3,4 Programmes Department, Population Council, Jabi, Federal Capital Territory , Abuja, Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Matthew Alabi For correspondence: ayoalabi85{at}gmail.com Leanne Dougherty 2 Programmes Department, Population Council , Washington DC, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Eno-Obong Etim 1,3,4 Programmes Department, Population Council, Jabi, Federal Capital Territory , Abuja, Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site Adebola Adedimeji 1,3,4 Programmes Department, Population Council, Jabi, Federal Capital Territory , Abuja, Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Adebola Adedimeji Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Background Family Planning Counselling (FPC) involves information exchange on contraceptive methods between a provider and client and providing appropriate support in choosing a method that best suits the client’s needs. Access to sexual and reproductive health information enables women to make informed health decisions. However, the low modern contraceptive prevalence among women in northern Nigeria may be attributed to poor FPC and exposure to FP messages, among other factors. This study examines the impact of quality FPC and exposure to FP messages on modern contraceptive use. Methods We conducted a cross-sectional survey of 676 family planning clients aged 15-49 from 163 health facilities in Northern Nigeria. Quantitative data were collected using client exit interviews. The analysis included a binary logistic regression to predict the odds of modern contraceptive use using MII Plus and other explanatory variables. Result Only 29% received quality counselling about methods, while 35% were exposed to FP messages. The quality of counselling assessed using MII Plus did not predict modern contraceptive use. However, higher odds of using modern contraceptives were found among clients who reported their provider asked about their previous family planning experience (aOR=3.81; 95% CI: 1.04-13.99) and explained how the selected FP method works (aOR=5.51; 95% CI: 1.11-27.30). Clients who received FP messages from a place of worship (aOR=11.97; 95% CI: 1.76-81.62) and a community ruler (aOR=6.52; 95% CI: 1.02-41.58) had higher odds of using modern contraceptives. Conclusion Improving the quality of FPC and expanding exposure to FP messages through effective community structure can enhance the uptake of modern contraceptives in northern Nigeria. Background Trends in modern contraceptive use over the past decade in Nigeria suggest a slow pace, with a Modern Contraceptive Prevalence Rate (mCPR) of 10.5% in 2011, 10.8% in 2016, and 18.3% in 2021( 1 ). The 2022 estimate of 18% is considerably lower than the Federal Government of Nigeria’s target of 27% mCPR by the year 2020, despite various efforts to improve uptake including training of health workers and personnel on postpartum family planning, and implementation of task-shifting/sharing policy for essential healthcare services, among others( 2 ). Besides the low national mCPR, there are regional differentials, with the highest mCPR of 21% in the southwest region, followed by the southeast (15%), north-central (12%), northeast 4% and northwest (3%) all lower than the national target( 2 ). Studies 3-11 that have explored factors associated with modern contraceptive use among women, acknowledged the significant influence of socioeconomic variables and health-seeking behaviour. Studies( 3 – 8 ) have also highlighted the influence of contextual factors and the mixed effects of fertility behaviour fueled by cultural norms and religious beliefs, autonomy, misconceptions, and fear of side effects as important predictors of modern contraceptives. However, there is evidence that Quality of Counseling (QoC) is associated with contraceptive utilization, patient outcomes, and reproductive health-seeking behaviour( 9 – 13 ). The importance of quality counseling has received renewed interest necessitating the development of appropriate measures for assessing quality counseling. Examples of approaches for measuring QoC include process quality, which measures the exchange of information and interpersonal relationships that occur between the provider and client during care( 14 ). Another measure is the Balanced Counseling Strategy (BCS), developed by the Population Council in the late 1990s to adapt counseling to an individual client’s specific reproductive health needs and enable the individual to select a method that best satisfies their specific needs( 15 , 16 ). All these measures have been positively associated with contraceptive intention and continuation among users( 17 , 18 ). Recently, researchers have focused on using the Method Information Index (MII), and by extension, the MII Plus to assess the quality of counselling received by family planning clients. These measures are positively associated with contraceptive continuation regardless of the method( 17 , 19 , 20 ). The MII is computed among current contraceptive users based on their responses to three questions, which ask whether the client received information on other contraceptive methods other than the one currently in use, whether clients were told about any possible side effects from using the current method, and whether they were provided with information on what to do should they experience any side effects ( 21 ). The MII Plus included one additional question that asks whether the client was told about the possibility of switching to another method should the method selected is deemed unsuitable ( 14 ). Each question requires a “yes” or “no” response. Those responding yes to all three or four questions are considered to have received adequate counseling, otherwise, counselling is considered inadequate( 22 ). Besides, studies( 23 – 29 ) have also explored the association between exposure to family planning (FP) messages and use of modern contraceptives. Evidence from these studies suggest exposure to FP messages via different conventional and social media channels, was associated with a higher likelihood of modern contraceptive use. Although, few studies ( 24 , 30 ) have reported negative effects. Also, studies( 4 , 9 – 11 , 13 , 23 , 31 ) have highlighted how religious and traditional systems could shape the influence of the mass media. The MII has been adopted as one of the core measures for family planning 2020 initiative and constitute the primary indicator that addresses the issue of counselling, informed choice, and process quality ( 20 ). To our knowledge, no study has examined the influence of quality family planning counselling, and exposure to family planning messages on modern contraceptives use, and whether or not they predict usage in the northern regions of Nigeria where evidence suggests low uptake of modern contraceptives. The objective of this study is to bridge the gap in literature by examining the quality of client-provider interaction and exposure to family planning messages on modern contraceptive use.. MATERIAL AND METHODS Study Setting The study was conducted in six northern Nigerian states: Kano, Kaduna, Sokoto (Northwest), and Bauchi, Borno, and Yobe (Northeast). These states were purposively selected due to their participation in the Routine Immunization (RI) and, by extension Primary Health Care (PHC) Memorandum of Understanding (MoU) implementation ( https://pdf.usaid.gov/pdf_docs/PA00WCCT.pdf ). The RI/PHC MOU was borne out of the desire to address the insufficient and unpredictable funding for RI and PHC services, and the suboptimal commitment from the government to healthcare, by addressing issues relating to ownership and management in northern Nigeria associated with low RI coverage and poor PHC indicators. Study Design and Sampling We conducted a cross-sectional health facility assessment with client exit interview and used a two-stage stratified sampling procedure in selecting the facilities. In the first stage, all LGAs in the RI implementation states have three ( 3 ) senatorial districts each. In ensuring coverage and spread in the evaluation states, the list of all the LGAs in each senatorial district was generated. On the assumption that implementation covers all the LGAs, fifty percent of the total number of LGAs in each state was selected proportionately (with exception of Borno). Although the evaluation LGAs were randomly selected, field realities such as security and access largely informed the final LGAs selected and surveyed as in the case of Borno. In each of the randomly selected LGAs, two PHCs were randomly selected and accessed to evaluate the efficiency and overall impact of the MoU. The targeted number of health facilities across all the LGAs in all the MoU states was 156, at two health facilities per LGA. In selecting health facilities, consideration was given to location (rural/urban) except for cases where health facilities were considered not accessible for security reasons and distance. A total of 163 Health Facility Assessments (HFA) were conducted across all the six MoU states. The additional seven health facilities were because of oversampling in Borno state. Twenty family planning clients were targeted per health facility in all the states. Hence, a total of 676 Client Exit Interviews (CEI) were conducted with family planning clients across all six states. Clients were selected to participate in the exit interview if they met the inclusion criteria, namely married women in the age group 15-49 years and accessing family planning services at the health facility. Data Collection Data collection was conducted concurrently across all six states between 14 th March and 8 th April 2022 following a pilot to assess the quality of the questionnaire. The questionnaire was programmed on mobile tablets using the SurveyCTO platform. The questionnaire, which was was translated into Hausa, the commonly spoken language in the study area, was adapted from the WHO Service Availability and Readiness Assessment (SARA) Questionnaire . Eligibility criteria included women, ages 15-49, willing to provide informed consent after being provided with information about the study. Measurement of Variables The primary outcome variable for this study is the use of modern contraceptives. The operational definitions for this and other selected explanatory variables are presented in Table 1 . The selection of variables was largely informed by the review of the literature. View this table: View inline View popup Download powerpoint Table 1: Showing the operational definition of outcome and the explanatory variables used Statistical Analysis Both descriptive and inferential analyses were performed. The descriptive analysis performed includes frequency count, percentages, means, and standard deviations. For inferential analysis, logistic regression was used to check for relationships among variables. The dichotomous nature of the outcome variable influenced the conduct of binary logistic regression. Variables included in the adjusted multivariate model were chosen based on their contribution to the model and literature review. We presented the results of the analysis as odds ratios (ORs) and 95% confidence intervals. The goodness of fit of the model was used to determine if the application of multivariate logistic regression followed the required assumptions and whether the model sufficiently fit the data. The Hosmer-Lemeshow test, which tests for goodness of fit for the logistic regression model, was used, with a small chi-square and large p-value indicating a good fit to the data (χ 2 =354.79, p>0.05(p=0.653). The analysis of the data was performed using Stata version 14 software. Ethical Approval and Informed Consent The study sought and received approval from the Population Council Institutional Review Board (Protocol Number 992). In Nigeria, ethical approval to conduct the study was obtained at the national and state levels. At the national level, approval was granted by the National Health Research Ethics Committee with approval number NHREC/01/01/2007-17/01/2022, while the State Health and Research Ethics Board in each of the study sites provided approval at the state level. Informed consent was presented to the study participants to read and either sign or thumbprint to give their consent. Thus, only caregivers who gave their consent were interviewed. RESULTS Description of Study Participants Table 2 presents the profiles of the study participants. Participants were aged 16-49 years (mean 30), one quarter had no formal education, and nearly two-thirds were working, and more than half are literate with about 70% completing primary education or higher. One in four women reported reproductive decisions, including the use of contraception, are made by partners only. View this table: View inline View popup Table 2: Socio-demographic Characteristics Quality of Counselling and Exposure to family planning Messages As shown in Table 3 , less than one-third (29%) of the women received adequate counseling, suggesting the quality of counselling was generally low. Assessment of other counselling indicators also revealed that only 28% reported the provider made use of visual aids during the counseling, while 32% reported their provider asked questions relating to family planning history and their preference for contraceptive methods. About 17% have heard or were exposed to family planning messages in the last 30 days preceding the survey. View this table: View inline View popup Table 3: Client-Provider Interaction and Exposure to Family planning messages View this table: View inline View popup Table 4: Relationship between sociodemographic factors, quality of FPC, media exposure to family planning messages and use of modern contraceptives Prevalence and Pattern of contraceptive use The result of contraceptives prevalence is presented in Figure 1 . Among the participants, injectables (42%), was the most commonly used method, followed by IUD and implant, accounting for (18%). Download figure Open in new tab Fig. 1: Pattern of Contraceptive Use among family planning clients Multivariate Analysis We performed a binary logistic regression analysis to determine factors influencing contraceptive use. At the individual level, region of residence, literacy level, being in employment, and decision-making autonomy were significantly associated with the use of modern contraceptives. Women residing in the northwest region (aOR=0.33 95% CI: 0.15-0.73) were less likely to use contraceptives relative to their counterpart in the northeast. Literate participants had higher odds of using contraceptives compared to those who are not literate (aOR=4.35 95% CI: 1.03-18.36). Those in employment were twice more likely to use contraceptives compared to unemployed women (aOR=2.17; 95% CI: 1.06-4.46). Caregivers with the ability to jointly make decisions regarding contraceptive use with their partner were nearly 3 times more likely to use contraceptives than those who have no autonomy to make decisions Quality of Family Planning Counselling (FPC) MII Plus was the principal explanatory variable used to assess quality of FPC in this study, besides other measures. However, while the effect of MII Plus was not statistically significant in predicting contraceptive use (p>0.05), the effect of some other client-provider interaction and communication variables was statistically significant. For instance, clients who reported that their FP provider asked questions about their previous family planning experience had higher odds (aOR=3.82 95% CI: 1.04-13.99) of using contraceptives relative to women who reported no. Also, clients who reported their providers talked about how the selected method works (aOR=5.51; 95% CI: 1.11-27.30) were more likely to use contraceptives. However, clients who reported their provider told them when to return for follow-up showed lower odds (aOR=0.06; 95% CI: 0.01-0.34) of using contraceptives relative to those who reported no. Media Exposure to family planning messages Our findings showed that sources of information on family planning were significantly associated with contraceptive use. Clients who reported a place of worship (aOR=11.97; 95% CI: 1.76-81.62) and community leaders (aOR=6.52; 95% CI: 1.02-41.58) as their source of information on FP showed higher odds of using contraceptives relative to those not exposed to any of these sources. Contrary to expectations, clients that reported receiving family planning messages from a health worker (aOR=0.26; 95% CI: 0.08-0.78) were less likely to use contraceptives when compared to those who did not. DISCUSSION Our study revealed a high prevalence of contraceptive use among the family planning clients, with injectables being the most commonly used method. The high prevalence and pattern of contraceptive use have been supported in previous studies ( 12 , 32 , 33 ). Contrary to previous studies,( 14 , 19 , 34 , 35 ) we found no association between quality of FPC and contraceptive use. Although, previous studies have largely associated MII Plus with contraceptive continuation rather than use. However, we found a significant association between other counselling and communication measures with contraceptive use. There is evidence regarding how quality family planning counseling can support women and their partners in adopting contraceptive methods that suit their needs, in addition to assisting them in solving any potential problem that may arise as a result of the use of a particular method( 34 ). Although different contraceptive counseling strategies have been explored in the literature and found to improve contraceptive use and reduce unmet needs. However, there seems to be no clear consensus regarding the best approach to deliver family planning counseling that will be effective in improving contraceptive uptake, reduce unmet need and improve overall client satisfaction( 36 ). This suggest gap in evidence, with further investigation required. Furthermore, in contrast with most studies ( 11 , 29 , 37 ) our findings showed exposure to family planning messages was not significantly associated with the use of contraceptives. This may be connected with the low exposure to family planning messages among the women. Although a few studies( 24 , 30 ) have also reported a non-significant effect of media exposure. There is evidence in literature on how effective mass media can promote accurate information about contraceptives, stimulating attitudinal and behavioural changes, increasing community awareness and mobilization and combating the spread of misinformation and socio cultural and religion myths regarding the use of contraceptives ( 38 – 42 ). Our study found sources of information about family planning were significantly associated with contraceptive use. Receiving information about family planning from a place of worship and a community leader was significantly associated with the likelihood of using contraceptives. These findings were consistent with previous studies( 9 , 13 , 23 , 37 ) and further reiterate the important roles played by religious institutions and community leaders in promoting the use of modern contraceptives. This is particularly important within the study context because the use of contraceptives is fundamentally shaped by religious and cultural factors. In line with previous studies( 43 – 45 ), our findings revealed that individual-level factors, namely literacy level (being able to read or write), currently working, and having autonomy, were significantly associated with the use of contraceptives after adjusting for other factors. Understandably, being able to read or write might allow for a better understanding of counselling information received from the FP provider, especially when communication is a barrier( 46 ). Similarly, active engagement in economic activity relative to being unemployed and being able to jointly decide on contraceptive use with their partner suggests some level of economic and reproductive health empowerment. These no doubt enhances the prospect of using contraceptives among women. The strength of this study is sampling participants from clients visiting health facilities to access contraceptives, which helped to reduce possible recall bias since questions were asked about their last visit. Regardless, there are a few limitations such as the cross-sectional design, which limited ability to infer a causal relationship, coupled with the limited sample size might have possibly influenced our study outcome. Regardless of these limitations, our findings were in most cases consistent with previous findings, in addition to making important contributions to literature. Conclusion The low quality of family planning counseling and poor exposure to family planning messages suggest the need for developing strategies that will help in strengthening QOC and exposure to multiple sources of information about family planning. This can help to promote contraceptive use. The outcome of this study further echoes the important role played by religious and community leaders in championing and promoting positive social norms toward achieving enhanced modern contraceptive uptake. Data Availability All data produced in the present study are available upon reasonable request to the authors Acknowledgement The authors would like to thank the Bill and Melinda Gates Foundation for funding the study. Also, all the study participants and stakeholders across all the six states where the study was conducted are well appreciated for their support during the research work. Footnotes Funding: The Bill & Melinda Gates Foundation funded and reviewed this research article. 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Quality of care in family planning services in Senegal and their outcomes . BMC Health Serv Res . 2017 Dec ; 17 ( 1 ): 346 . OpenUrl PubMed View the discussion thread. Back to top Previous Next Posted April 03, 2024. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following DOES QUALITY OF COUNSELING AND EXPOSURE TO FAMILY PLANNING MESSAGES INFLUENCE THE USE OF MODERN CONTRACEPTIVES AMONG WOMEN IN NORTHERN NIGERIA? Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. 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